Health Care Coverage for You and Your Family

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Health Care Coverage for You and Your Family!

• Welcome

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Agenda

• Whats new this year
• Who is eligible to enroll
• Plan options
• Cost of health coverage
• How to enroll
• Enrollment support
• Questions

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Whats New for 2007-2008?

• ActiveCare 1
• Plan year deductible increased from 1,050 to
  1,100 per individual
• ActiveCare 2
• 100 inpatient hospital copay per day (500
  maximum copay per admission, 1,500 maximum copay
  per plan year)
• 100 outpatient surgery copay per visit
• 100 emergency room copay per visit (copay waived
  if admitted)
• Copays are in addition to deductible and
  coinsurance
• ActiveCare 3
• No plan changes
• Premium increase (approximately 7)

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Employees Eligible to Enroll
Active contributing TRS member?
You may be eligible
If Yes
If No
Regularly work 10 or more hours per week?
You may be eligible
If Yes
If No
You are not eligible
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Employees NOT Eligible to Enroll

• State of Texas employees or retirees
• Higher education employees or retirees
• Most TRS retirees, including those back at work
• These individuals are not eligible to enroll for
  TRS-ActiveCare coverage as employees, but they
  can be covered as a dependent of an eligible
  employee

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Eligible Dependents

• Spouse (including a common law spouse)
• Unmarried (including divorced) children under age
  25
• Natural child
• Adopted child
• Stepchild
• Foster child

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More Eligible Children

• An unmarried child under the legal guardianship
  of the employee
• An unmarried child in a regular parent-child
  relationshipwith the employee
• The child's primary residence is the household
  ofthe employee
• The employee provides at least 50 of the child's
  support
• Neither of the child's natural parents resides in
  that household
• The employee has the legal right to make
  decisions regarding the child's medical care
• An unmarried grandchild whose primary residence
  is the household of the employee and who is a
  dependent of the employee for federal income tax
  purposes

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More Eligible Dependents

• Unmarried children (any age) mentally retardedor
  physically incapacitated
• Siblings over age 25 or parents are not the
  children of an employee and do not meet the
  definition of an eligible dependent
• Any other dependents required to be covered under
  applicable law

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Newborns

• Covered the first 31 days if employee has
  coverage
• To continue coverage, employee must add newborn
  within 60 days after the date of birth
• However, an employee has up to one year after the
  newborns date of birth if
• Employee has employee and family or employee
  and child(ren) coverage at the time of birth and
  at the time of enrollment

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PPO Plan Options

• ActiveCare 1, 2 and 3

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PPO Features ActiveCare 1, ActiveCare 2 and
ActiveCare 3

• Administered by Blue Cross and Blue Shield of
  Texas and Medco
• No primary care physician (PCP) required no
  referrals required to see a specialist
• Select any provider for care within the PPO
  network or outside the network
• When you receive care inside the network, you
  receive the highest level of benefits
• When you receive care outside the network, you
  still have coverage but you may pay more of the
  cost
• Worldwide coverage for emergency and
  non-emergency care

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Network vs. Non-Network Providers

• Network Providers
• Receive highest level of benefits
• No claims to file
• No balance billing
• Non-Network Providers
• Receive non-network level of benefits
• Must file own claims
• May be billed for charges exceeding allowable
  amount

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Non-Network Providers

• ParPlan Providers
• Receive non-network level of benefits
• No claims to file in most cases (ParPlan provider
  will usually file the claims)
• No balance billing ParPlan providers cannot bill
  for costs exceeding the allowable amount

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Coverage Outside Texas

• BlueCard PPO Program
• (for enrollees living or traveling outside of
  Texas)
• More than 85 percent of all doctors and hospitals
  contract with Blue Cross and Blue Shield Plans
• Outside of the U.S., you have access to doctors
  and hospitals in more than 200 countries
• Network level of benefits
• Claims filed by providers
• No balance billing

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Deductibles (Plan Year)
Deductible The amount of out-of-pocket expense
that must be paid for health care services before
becoming payable by the health care plan
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Coinsurance
Coinsurance The percentage of medical expenses
that you and the health plan share
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Office Visit Copay
Copayment (Copay) The amount paid at the time of
service for certain medical services and
prescription drugs copays depend on whether the
doctor is primary or a specialist Specialist Any
physician other than a family practitioner,
internist, OB/GYN, and pediatricians
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Preventive Care
Copayment (Copay) The amount paid at the time of
service for certain medical services and
prescription drugs copays depend on whether the
doctor is primary or a specialist Specialist Any
physician other than a family practitioner,
internist, OB/GYN or pediatrician
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Out-of-Pocket Maximum(excludes copays and
deductibles)
Out-of-Pocket Maximum When you reach your
plans of out-of-pocket maximum, the plan then
pays 100 of any eligible expenses for the rest
of the plan year.
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Preauthorization Required

• All inpatient hospital stays
• Treatment of all serious mental illness, mental
  health care and chemical dependency
• Home health care
• Hospice
• Skilled nursing facility
• Home infusion therapy

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Special BeginningsPrenatal Program

• Available now to ActiveCare 1, 2 and 3 plan
  participantsat no cost
• Program is available from pregnancy through six
  weeks after delivery
• Helps mothers take better care of themselves and
  their babies
• Assesses pregnancy risk level and provides close
  monitoring through a series of calls from an
  experienced obstetrical nurse
• Call 1-800-462-3275 to enroll or ask questions
  about the program

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Disease Management ProgramsActiveCare 1, 2 and 3
PPO Plans

• Voluntary programs available now to ActiveCare 1,
  2 and 3 plan participantsat no out-of-pocket
  cost
• Designed for those diagnosed with
• Asthma
• Diabetes
• Congestive heart failure
• Coronary artery disease
• Metabolic syndrome (high blood pressure, high
  cholesterol)
• Lower back pain
• End stage renal disease

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Disease Management Programs (Cont.)

• Enrolling in a program can help
• Decrease the intensity and frequency of symptoms
• Enhance self-management skills
• Minimize missed days at work
• Enrich quality of life
• Claims and pharmacy data review, preauthorization
  prior to a hospitalization or a physician
  referral are some of the factors that help
  determine if a disease management program is
  right for the plan participant
• Blue Cross and Blue Shield of Texas will notify
  doctor by letter if it finds that the plan
  participant would benefit by enrolling in a
  program
• Call 1-800-462-3275 to enroll

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Disease Management Programs What You will
Receive

If a representative from Blue Cross and Blue
Shield of Texas or LifeMasters calls or leaves a
message for you, talk to them! They are calling
to help improve your health and well being.
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Blue Access for Members(Registration required)

• Available to ActiveCare 1, 2 and 3 enrollees
• Blue Access for Members link on TRS-ActiveCare
  Web site and www.bcbstx.com/trs
• Check the status of a claim
• Confirm who is covered under the plan
• View and print detailed claim information
  (Explanation of Benefits)
• Opt-out of receiving paper copies of their
  Explanation of Benefits
• Sign up to receive email notifications of new
  claim activity
• Request a new or replacement ID card or print a
  temporary member ID card
• Access to health and wellness information

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Take a Health Risk Assessment

• Confidential online survey to help you learn more
  about your individual health risks
• Takes 10-15 minutes to complete
• Individualized report provided with guidance and
  suggestions for next steps to improving your
  health
• Available through Blue Access for Members
• Click on My Health tab, then select the Health
  Wellness icon to Take a Health Risk Assessment
• Your information is kept confidential
• Information will not be released to your employer

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Prescription Drug Benefits

• ActiveCare 1, 2 and 3

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Prescription Drug BenefitsWhats New

• No plan changes, no copay changes
• Retail Pharmacy ProgramActiveCare 2 and
  ActiveCare 3No changes
• Retail copays for maintenance medications
• First two fills of maintenance medication at
  retail short-term copay
• Third (3rd) fill of maintenance medication at
  retail copay increase
• Retail copays for short-term medications did not
  change
• Mail order copays did not change
• Separate 50 drug deductible per family member
  for ActiveCare 2 and ActiveCare 3 did not change

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Prescription Drug Benefits
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Prescription Drug Benefits
Note When using a non-network pharmacy, you must
pay the entire cost and submit a claim form to
Medco. You will be reimbursed the amount that
would have been charged by a network pharmacy,
less the required copayment.
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Prescription Drug Benefits
Note When using a non-network pharmacy, you must
pay the entire cost and submit a claim form to
Medco. You will be reimbursed the amount that
would have been charged by a network pharmacy,
less the required copayment.
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Prescription Drug Benefits

• Once the deductible is satisfied, the member pays
  the applicable copay
• Member-paid cost differences between a brand-name
  drug and a generic equivalent do not apply to the
  deductible

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Prescription Drug Benefits

• Once the deductible is satisfied, the member pays
  the applicable copay
• Member-paid cost differences between a brand-name
  drug and a generic equivalent do not apply to the
  deductible

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Prescription Drug Benefits

• ActiveCare 2 and 3 Member pays the difference
• You pay the difference if a brand-name
  prescription is dispensed when a generic is
  available
• You pay the generic copay plus the difference in
  cost between the brand-name prescription and what
  the cost would be if the generic drug had been
  purchased, regardless of doctor DAW (Dispense As
  Written)

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Prescription Drug Benefits

• Drug Formulary
• Preferred and Non-Preferred Medications
• Copays
• Preferred Prescriptions Drug List
• Generic Medications

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Prescription Drug Benefits

• Prior Authorization
• Program designed to ensure the safety of
  participants and help contain costs
• May review some or all of the following
  information to assure an appropriate coverage
  decision
• Patient diagnosis
• Indications for prescribed drug use
• Dosing
• Duration of therapy
• Patient drug profile
• Potentially dangerous drug interactions

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Prescription Drug Benefits
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My Rx Choices (Pilot Program replaced Savings
Advisor)

• Pilot Participant
• Initiated 12/1/2006 goes through 2/28/2007
• Features include
• Personal assessment of cost-saving opportunities
  based on the members prescription plan
• Best-value alternatives based upon greatest cost
  savings to the member presented in order from
  highest value to member
• Brand-to-generic and retail-to-mail compare
  options available
• Explanation of complicated concepts in
  easy-to-understand terms

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My Rx Choices Available through 800 or on
www.medco.com

• As of 3/1/2007
• 8,813 registered TRS-ActiveCare members
• 17,129 wizard starts
• 1,694 forms downloaded
• 12 of the time members switched to cost saving
  alternatives

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My Rx Choices
Medco can facilitate on generic equivalents
received through mail order
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My Rx Choices
Members may print a kit to discusslower-cost
alternatives with their doctor
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Coverage Categories

• Employee Only
• Employee and Spouse
• Employee and Child(ren)
• Employee and Family

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Choosing a Coverage Category

• If employee and spouse both work for a
  participating entity
• A spouse may be covered as an employee or as a
  dependent of an employee
• Only one parent can cover dependent children

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Application to Split Premium

• Married couples working for different
  participating entities may pool funds
• Optional
• Requires an Application to Split Premium form to
  be completed by both employees and employers

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How to Enroll

• 2007-2008 Plan Year

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Who needs to enroll?

• For new coverage or changes, complete an
  Enrollment Application and Change Form
• If you enrolled in 2006-2007 and do not wish to
  make changes to your current health benefit plan,
  you do not need to submit an enrollment
  application
• You must complete an application if declining
  coverage even if you previously declined
  coverage

Complete, sign, date and submit formsto your
Benefits Administrator
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Can Changes in Coverage Be Made After Your
Application Has Been Submitted?

• Changes can be made up to the end of your
  enrollment period
• Plan choices will remain in effect through August
  31, 2008 unless theres a special enrollment
  event such as
• Marriage or divorce
• Birth, adoption or placement for adoption of a
  child
• A child marries or reaches age 25
• A court order to provide health coverage for an
  eligible child
• Loss of coverage
• Changes must be made within 31 days after the
  event date (special rules apply to newborns)
• New application must be submitted for any change

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Cafeteria Plan Vendor(s)

• Making a change through the Section 125 vendor
  does not automatically generate a change to
  coverage under TRS-ActiveCare
• All changes to TRS-ActiveCare must be signed,
  dated and submitted on an Enrollment Application
  and Change Form

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Important NoticeSupplemental Coverage

• TRS does not offer or endorse any supplemental
  coverage for any of the health coverage plans
  available under TRS-ActiveCare
• To obtain information about any coverage that
  claims to be a companion or supplement to any
  TRS-ActiveCare plan, employees should contact
• The organization making such offering and/or
• The Texas Department of Insurance (TDI)
  http//www.tdi.state.tx.us or the TDI Consumer
  Helpline [phone]

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Your TRS-ActiveCare ID card will be mailed to
your home

• ActiveCare 1 and 3
• New ID cards will not be issued to current
  participants unless changing plans new enrollees
  will receive new cards
• ActiveCare 2
• All enrollees will receive new cards
• HMO plans
• All HMO participants will receive new cards
  (except for Mercy Health Plans)
• Each individual covered under the plan will
  receive a card

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Enrollment Support

• Dedicated Customer Service
• ActiveCare 1, 2 or 3 1.866.355.5999(Blue Cross
  and Blue Shield of Texas and Medco)
• FirstCare Health Plans 1.800.884.4901
• Legacy Health Solutions 1.877.410.2432
• Mercy Health Plans 1.800.617.3433
• Scott and White Health Plan 1.800.321.7947
• Valley Baptist Health Plans 1.800.829.6440

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Enrollment Support

• Available Online
• Enrollment guide (English and Spanish)
• Downloadable forms(enrollment application, split
  premium, claim form, etc.)
• Provider locator
• Frequently asked questions

www.trs.state.tx.us/trs-activecare
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Blue Access for Members

• Available to ActiveCare 1, 2 and 3 enrollees
• BAM link now on TRS Web site and
  www.bcbstx.com/trs
• Check the status of a claim
• Confirm who is covered under the plan
• View and print detailed claim information
  (Explanation of Benefits)
• Opt-out of receiving paper copies of your
  Explanation of Benefits
• Sign up to receive e-mail notifications of new
  claim activity
• Request a new or replacement ID card or print a
  temporary member ID card
• Take a Health Risk Assessment

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Questions

• Thank you for attending